HAZMAT FORM

Because of potential liability problems, we are required to have this form signed and submitted before we ship ANY hazardous material.

Name
*

Prefix First Name Last Name

Company Name

E-mail
*

Shipping Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number

-
Area Code Phone Number

BIRTHDAY
*

/
Month
/
Day Year

Date Date Picker Icon

As the buyer of the hazardous materials I fully understand the material I am purchasing is considered hazardous andcould cause bodily harm, or even death.

I assume all responsibility for its safe use and proper use, storage and disposal.

I understand that all records of sales are, if requested, available to law enforcement.

I certify that I am at least 18 years of age.

I release Chemistry Connection, an Arkansas company of all liability when using and disposing of this product.

This is a waiver, informed consent, and covenants not to sue. I am purchasing this product and understand the danger using it. I do hereby forever release, discharge, and hold harmless Chemistry Connection and the owners and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my purchase and my participation using this product including any injuries resulting there from.THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULTOF (1) Buying the product(s), use of the product(s) (2) ANY uses of the product.

By my submission I indicate that I have read and understand this Waiver of Liability. I am aware that this is a waiver and a release of liability and I voluntarily agree to its terms.